Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Tuesday, September 19, 2006

Unnecessary Consultations

In When Day Care Calls, Part III, Dr. Flea is annoyed that a parent wants an orthopedic consult on the benign to-be-outgrown condition of metatarsus adductor (translation: one of the kid's legs turns funny), all because the Day Care Director suggests there is more to be done. Flea gives in and refers the patient, against his better judgement.

I'm left to wonder, why the distress?Is Flea worried the orthopedic surgeon will think he's an idiot for referring?Is Flea worried the orthopedic surgeon will find something he missed? (shame, lawsuits, you name it)Is Flea worried about the needless waste of healthcare dollars? (He hates it when his patients go to the ER unnecessarily, hates it even more when the ER docs don't consult with him)Is Flea worried about wasting the orthopod's time?Is this an issue of control for Flea? Won't he look bad if the orthopedist says "You arrived just in time, it's so good you have that wonderful DayCare Director to look out for you!" Will he gloat when the orthopod says "The pediatrician is right, they're nothing to worry about and little darling will outgrow this soon; never ever listen to those Day Care directors!"

Flea seems to be upset that the Day Care Director would second guess him, would suggest a medical consult despite his reassurances and her lack of medical training, and he may be insulted that the parent won't take his word on it for what is right.

It seems to be the nature of the beast that patients wonder if they're getting the best care. Doctors-bashing is fun, and we're bombarded by the media with images of physicians who've missed the diagnosis, who are lazy, money-hungry, egotistical and owned by the pharmaceutical industry.

Psychiatry has its own issues with referrals for consultation. Most psychotropic medications --especially anti-depressant and anti-anxiety medications-- are prescribed by primary care doctors, not psychiatrists. And primary care docs worry that they'll insult a patient if they say "You Need A Psychiatrist." Plus, in issues related to mental health, everyone is their own Day Care Director: often psychiatric symptoms are the same as what we might call Normal Reactions or You'd-feel-this-way-too-if-you-experienced-what-I've-experienced. Some patients resist the idea that their symptoms warrant getting help, they come for help at the insistence of a relative, a friend, the Day Care Director. Others long for a diagnosis, an explanation that absolves them of responsibility and that might even be something easily cured. Add to this the fact that psychiatric illnesses often include a symptom called Impaired Insight-- the inability to accurately see oneself (--"Damn it, I wouldn't be so irritable if you weren't such a Jerk!!!) and outside informants, Day Care Directors in assorted forms, can add invaluable information to the treatment process.

In a moment of empathy with Flea, however, I will say I prefer it when the Day Care Director says, "Maybe you should consult with a psychiatrist and see if there's a problem here," rather than, "You need to see a psychiatrist to get 900 mg of Lithium and 15 mg of Zyprexa for your Bipoloar Disorder."

10 comments:

Certainly, the availability of information on the Internet has not helped with the issue Flea described. I know I am guilty of saying, "But I read...." But then I did that before Internet access became so ubiquitous.

I recall that in my early twenties I went to the library reference desk, handed them my license as required, and borrowed a DSM because I was curious.

Could it be an issue of respect for Flea? Shouldn't someone who is his patient's parent have enough trust in him to not seriously entertain the opinions of others, especially, non-physician or medically trained others, but to defer to the physician they know and who knows them?

I will say this for my PCP. He is not comfortable prescrobing psychotropic drugs and is not afraid to say it. He told me that and referred me to a bonafide shrink---but, my new insurance has a $1000 in network deductible and $2000 out of network deductibe to see the psychiatrist and this is a problem for me, a heartbreaking problem. I know I need help, but can't afford it long term so I have thought of going back to my PCP and presenting the dilemma to him. I am impresed, however, that he knows his limitations and refers to a psychiatrist. It seems that too many GPs are treating psychiatric issues, many times inappropraitely, but what do you do when TV commercials make it seem that popping a Paxil or Effexor is like candy?

I have never heard of "impaired insight" until now. I think I'll look it up!

The State of Connecticut has gone as far as to enact a specic law that forbids teachers from giving any psychotropic medication advice. It seems to me that, for parents who are vulnerable to the "authority" of teachers & guidance counselors, this is a major step in the right direction.

"Others long for a diagnosis, an explanation that absolves them of responsibility and that might even be something easily cured."

This quote rather gets my goat.

After 20 years, TWENTY YEARS, of wondering what the hell was wrong with me, and why did I keep failing, no matter how hard I tried, and put EVERYTHING into, well, can ya blame me for wondering if there was something going on, ie, a diagnosis, that would help me understand that I was a runner in a race, but I had no shoelaces, and didn't even know there was such a thing and that I was missing them? A runner in such a state is going to keep stumbling no matter how hard they try . . .

Can you blame me for wondering? That 20 years of continuing to get back up again and keep trying, I think, would be a good argument against this kind of . . . er, attitude or thinking that I've come across in different ways from both my ologist and my iatrist . . .

It's like for those twenty years, I was bashing up against an invisible wall, but I'd get up again and run at it from a different angle . . . the diagnosis FINALLY, serving as though someone had thrown paint on the wall, and I now know WHAT it is that has been interfering with me my whole life . . .

I don't think this diagnosis serves as an explanation that absolves me of responsibility, but when one has tried as hard as I have, and still struggled and fallen, it, well, when one HAS done everything one could do, THAT, itself, is what kind of takes any "fault" away from the situation, the stumble, the fall; that I've tried as hard as I can. Now, without the diagnoses, I would still be thinking it was ALL ME, and that I must therefore be extremely defective in character, among other ways . . . .

And, while I know there's not many easy cures for much of anything, the hope of some kind of a cure, even if unrealistic, is that something to be so ridiculed? Can you BLAME me that after 20 years of struggle . . . 20 years of finding each and every minutely and excruciatingly painful way that I was, I thought, insufficient to this challenge called life, that I might have some kind of a silly hope for an end to that that did NOT involve self-harm?

Sorry! I am not railing at YOU, personally, well, I guess it seems so, but rather, this attitude/way of thinking that seems to be so prevalent . . .

I want any diagnoses that I have so I can UNDERSTAND what is going on with me, and WORK with it, around it, whatever, better . . . as my ologist puts it, I want a sense of mastery, a sense of self-mastery, too, about the issue.

I spent one glorious year teaching precious Spanish speaking 3rd graders. We had a questionnaire that both the teacher and parent filled out if we had "concerns" about the child. The school counselors then looked at it. Then we were to only "suggest" to the parent that they might want to visit the pediatrician. This is in Texas. We were clearly told that only a physician could diagnose ADD and not to mention it directly.

I predict that because of insurance getting more and more expensive and paying for less and less treatment, there will be much more questioning of physicians and their treatment and testing recommendations.

I do not, however, understand a person listening to a daycare worker.

There is no way for us to learn everything regardless of how smart we are or think we are. We have to rely on professionals every day, from our hair-stylist to our attorney to our doctor.

Unfortunately, any profession where one deals with the public will open one to dealing with the less than intelligent.

I don't think teachers should make medication recommendations, however I find the concept of making it illegal to converse an interesting one.

My reference to personal responsibility and the longing for a psychiatric diagnosis was a direct hit upon my friend, Roy, who likes to talk about his "ADD". He's made of tough stuff and can tolerate my affectionate ribbing.

After 20 years, TWENTY YEARS, of wondering what the hell was wrong with me, and why did I keep failing, no matter how hard I tried, and put EVERYTHING into, well, can ya blame me for wondering if there was something going on, ie

******

I have your back on this one. Same thing, only not quite 20 years. OK, so maybe I don't have full fledged borderline personality disorder, but many of the "characteristics." Thanks. I am glad to know that because my gut said that there had to be more than MDD going on, something more fundamental, foundational if you will.

One psychiatrist told me he felt that "labels weren't helpful." Hmm I wonder what would happen if one heard that line from a cardiologist or oncologist?

Now I know about DBT. I wouldn't have without the DX.

Rant over. Besides I know that this blog is for psychiatrists and not mental patients, so I think I'll shut my piehole (or shoulld I say benzo hole) now.

I actually wasn't thinking that you were directing anything you said, Dinah, to me, it's just a trend I've noticed amongst the two mental health professionals I see, and from several places around the web.

I'm sorry if I came across defensive; what I really meant to do was say HEY, this is something I've noticed, and can I sort of debate the other side of the issue, without it being me taking what you said as being personally about me.

Anyway, I hope I've clarified a little. It's nice to come out of my shell a bit and get a little intellectual, or even if not that, just adult "conversation" and stuff, if you will.

I wasn't hurt or anything by what you said, nor did I think it was directed at me; I just sort of felt like it's a thing I wanted to point out a different angle.

Sorry to go on! I like most of your posts, and the kind of stuff you have to say; you express your point of view pretty well, and I enjoy reading that.

I spent a lot of time looking for the "why" of my own illness. Dr's kept pushing me to Internists, then Psychiatrists. Many a consult and no answers. Then I insisted on a neuro consult and most of the answers fell out quite easily.

It turns out that genetic tremor and a whole host of other symptoms tend to co-exist. No one knows if one causes the other, no one knows too much about the Essential Tremors.

One thing is known, if a patient has a genetic tremor, the odds are that patient also has a serious anxiety problem and a fair sized host of other minor --but highly annoying-- problems. BTW: having a fair sized anxiety problem doesn't seem to correlate to ET, at least from what I've read.

Patients often need to push for answers as sometimes there really are answers! Dr's cannot know everything, medicine is too big a field.

Herein we see a whopper of a problem: How does a Dr know which consult is the right one? When is a consult a good idea? etc.

There's also another problem: How to get a patient to accept "We don't have a clue as to what is wrong with you."

Dang, woman, you got some major guts messing with the Flea! He's a blog star way out in the atmosphere, too far away for me to ever reach.

I agree about the irritation of people coming in saying "my neighbor says I need an MRI for my back pain" (my version of your bipolar patient).

Sometimes I refer to a specialist knowing that they will reassure the patient that I was correct in my assessment or plan. Some patients just need to hear it from a "specialist." Usually I send the consultant a "heads up" email or note that the patient is coming and I outline what I told the patient I thought the problem was.

Consultants appreciate knowing that I know that the patients are unreasonable. They also appreciate the money.

I get referrals from them when their patients need primary care. It's all good.